Care of The Patient With A Neurological Disorder

CARE OF THE PATIENT
WITH A NEUROLOGICAL
DISORDER
Lecture by: M.K. Sastry
Overview of Anatomy and Physiology
• Nervous System
 Responsible for communication and control within the
body
 Interprets and processes information received and sends in
to the appropriate area of brain and spinal cord where
response is generated
 Body’s link to the environment
 Works with endocrine to maintain homeostasis
• NS reacts in a split second
• Endocrine works more slowly to secrete hormones
• Structural divisions
 2 Main Structural division:
1. Central nervous system (CNS)
 Brain and spinal cord
 Occupies a medial position in the body
 Responsible for interpreting incoming sensory information
and issuing instructions based on past experiences
 2 main structural divisions – cont’d

2. Peripheral nervous system (Lies Outside the CNS), divided
into 2 main divisions:
 Somatic nervous system
o Sends messages from the CNS to the skeletal muscles
o Voluntary muscles
o Sensory (Afferent) and Motor (Efferent) Neuron
 Autonomic nervous system
o Transmits messages from the CNS to the smooth muscle,
cardiac muscle and certain glands
o Involuntary
o Known as involuntary nervous system
Actions takes place without conscious control
o Sensory (Afferent) and Motor (Efferent) Neuron
-cells of the nervous system
• Cells of the Nervous system
 2 Broad Category:
1. Neurons, transmitter cells as they carry messages to and from the brain
and spinal cord.
2. Neuroglial or glial cells, support and protect the neurons while
producing cerebrospinal fluid (CSF), which continuously bathes the
structures of the CNS.
• Neuron (nerve cell)
 Basic nerve cell of nervous system
 Separate unit compose of:
• Cell body, the axon and the dendrites
 Cell body
• Contains a nucleus surrounded by cytoplasm
 Axon
• Cylindrical extension of a nerve cell
• Conducts impulses away from the neuron cell body
 Dendrites
• Branching structures that extend from a cell body and receive impulses
-cells of the nervous system (cont’d)
• Neuron (nerve cell) – cont’d
 Synapse
• A gap (space) between each neuron
• Defined as region surrounding the point of contact between
two neurons
• Between a neuron and an effectors organ, across which
nerve impulses are transmitted through the action of a
neurotransmitter
 Governed by “all or none” law
• Never a partial transmission of a message
• Impulse is either strong enough to elicit a response or too
weak to generate the message
• Neuromuscular junction
 Area of contact between ends of a large myelinated nerve
fiber and a fiber of skeletal muscle
 Necessary for functioning of the body
 Neurotransmitters act to make sure the neurological
impulse passes from nerve to muscle
• Neurotransmitters
 It modify or result in transmission of impulses between synapses
 Best known neurotransmitter are: Acetylcholine, Norepinephrine,
dopamine and serotonin.
 Acetylcholine (Ach)
• Role in nerve impulse transmission
• Spills into synapse area and speed transmission of impulse
• Cholinesterase (enzyme)
 Deactivate Ach once message or impulse has been sent
• Happens rapidly and continuously as each impulse is relayed
 Norepinephrine
• Effects on maintaining arousal (awakening from deep sleep) and
dreaming
• Regulation of mood (i.e. happiness and sadness)
• Neurotransmitters
 Dopamine
• Primarily affects motor function
• Involved in gross subconscious movements of skeletal muscles
• Role in emotional responses
• In Parkinson’s disease
 There is a decrease in dopamine, that’s why the person suffers from
tremors or involuntary, trembling muscle movements
 Serotonin
• Induces sleep
• Affects sensory perception
• Controls temperature
• Role in control of mood
• Neuron coverings
 Myelin
• White, waxy, fatty material
• Increases rate of transmission of impulses
• Protects and insulate fibers
 nodes of Ranvier
• Wraps the axon leaving the CNS in layers of myelin with
indentation
• Further increase rate of transmission, because impulse can
jump from node to node
• Neuron coverings
 Peripheral nervous system
• Myelin is produced by Schwann cells
• Outer membrane gives rise to another layer which is very
important in regeneration of cells called neurilemma,
functions of neurilemma:
 Helps to regenerate injured axons
 Regeneration of nerve cell occurs only in peripheral nervous
system
• Cells damaged in CNS results permanently (paralysis)
 Do not have neurilemma, so no regeneration occurs.
Figure 54-1
A, Diagram of a typical neuron. B, Scanning electron micrograph of a

neuron. C, Myelinated axon.
-Central Nervous System (CNS)
• Central Nervous System
 One of two main divisions of nervous system
 Composed of brain and spinal cord
 Functions somewhat like a computer but is much more
complex
 Cranium protects the brain
 Vertebral column protects the spinal cord
• Brain
 Specialized cells in the brain’s mass of convoluted, soft,
gray or white tissue coordinate and regulate the functions
of CNS
 Largest organ weighing about 3 pounds
 Divided into four parts
• Cerebrum
• Diencephalon
• Cerebellum
• Brain stem
 Midbrain; pons; medulla oblongata; coverings of the brain and
spinal cord; ventricles
• Brain
 Cerebrum
• Largest part of the brain
• Divided into left and right hemispheres
• Outer portion is gray matter
 Called - Cerebral cortex
• Arrange into folds called gyri (convolutions)
• Grooves are called sulci (fissures
• Corpus callosum
 Connecting structure or bridge
 Divides two hemispheres into for lobes
o Frontal lobe, parietal lobe, temporal lobe, occipital lobe
• Brain
 Cerebrum
• Fissure is a natural division between the left and right hemispheres
• Controls initiation of movement on opposite side of body
• Specific areas of cerebral cortex are associated with specific
functions:
 Frontal Lobe
o Written speech (ability to write)
o Motor speech (ability to speak)
o Motor ability – directs movements of body; left side controls the
right side of the body and the right side of the brain controls the
left side of the body.
o Intellectualization – the ability to form concepts
o Judgment formation
• Brain.. cont
 Cerebrum.. cont
• Specific areas of cerebral cortex are associated with specific
functions.. cont:
 Parietal Lobe
o Interpretation of sensory impulses from the skin such as touch,
pain, and temperature

o Recognition of body parts
o Determination of left from right
o Determination of shapes, sizes and distances
 Temporal Lobe
o Memory storage
o Integration of auditory stimuli
 Occipital Lobe
o Interpretation of visual impulses from the retina
o Understanding of the written word

• Brain
 Diencephalon
• Called interbrain
 It lies beneath the cerebrum
• Contains: thalamus and hypothalamus
• Thalamus
 Relay station for some sensory impulses while interpreting other
sensory messages (i.e. pain, touch, pressure)
• Hypothalamus
 Lies beneath the thalamus
 Role in control of body temperature, fluid balance, appetite,
emotions (i.e. fear, pleasure, pain)
 Controls sympathetic and parasympathetic divisions of autonomic
system as is the pituitary glands
 Influences heartbeat, contraction and relaxation of walls of blood
vessels, hormone secretion, and other vital body functions
• Brain
 Cerebellum
• Lies posterior and inferior to cerebrum
• Second largest portion of brain
• Contains two hemispheres with convoluted surface much like
cerebrum
• Responsible for coordination of voluntary movement and
maintenance of balance, equilibrium, and muscle tone
• Sensory messages from semicircular canals in inner ear sends
messages to cerebellum
 Brain stem
• Located at the base of the brain
• Consist of: Midbrain; pons; medulla oblongata;
• Connect spinal cord and cerebrum
• Carries all nerve fibers between spinal cord and cerebrum
 Brainstem..cont
• Midbrain
 Superior portion of brain stem
 Responsible for motor movement, relay of impulses, auditory
and visual reflexes
 Origin of Cranial Nerves (CN) III and IV
• Pons
 Connects midbrain to medulla oblongata
 “Pons” means “bridge”
 Origin of CN V through VIII
 Composed of myelinated nerve fibers and is responsible for
sending impulses to structures that are inferior and superior to
it
 Contains a respiratory center that compliments respiratory
centers located in medulla
 Brainstem.. cont
• Medulla oblongata
 Distal portion of brainstem
 Origin of CN IX and XII
 Controls heart beat, rhythm of breathing, swallowing,
coughing, sneezing, vomiting, and hiccups (singultus)
 Vasomotor center regulates diameter of blood vessels, helps
aid in BP control
Figure 54-2
Sagittal section of the brain (note position of midbrain).

• Coverings of brain and spinal cord

 Three protective coverings called meninges
• 1. Dura mater
 Outer most layer
• 2. Arachnoid membrane
 Second layer
• 3. Pia mater
 Inner most layer
 Provides oxygen and nourishment to nervous tissue
• These layers also bathe Spinal Cord and brain in
cerebrospinal fluid (CSF)
• Ventricles
 Four in all: 3rd, 4th, left and right lateral ventricle
 Spaces or cavities located in brain
 CSF
• Clear and resembles plasma
• Flows into subarachnoid spaces around brain and spinal cord
and cushions them
• Contains protein, glucose, urea, and salts
• Contains substances that forms a protective barrier (the
Blood-Brain Barrier)
 Prevents harmful substances to enter the Brain and SC
• Spinal Cord
 17 to 18 inch cord extending from brainstem to second
lumbar vertebra
 Two main functions:
• Conducting impulses to and from the brain
• Serving as a center for reflex actions
 Responsible for certain reflex activity such as knee jerk
• Sensory neuron sends information to cord, a central neuron
(within the cord) interprets impulse, and a motorneuron
sends message back to muscle or organ involved
• Message is sent, interpreted, and acted upon without
traveling to brain
Figure 54-3
Neural pathway involved in the patellar reflex.

Another example
- Peripheral nervous system
• Peripheral nervous system
 Comprise motor nerves, sensory nerves, and ganglia
outside brain and SC
 31 pairs of spinal nerves
 12 pairs of cranial nerves
 Autonomic nervous system
• Sympathetic nervous system
• Parasympathetic nervous system
• Spinal Nerves
 31 pairs and all are mixed nerves
 Transmit sensory information to SC through afferent
neurons and motor information from CNS to areas of body
through efferent neurons
 Named according to the corresponding vertebra (e.g C1,
C2)
 See next figure
• Cranial Nerves
 12 pairs
 Attach to posterior surface of brain, mainly brainstem
 Conduct impulses between head, neck, and brain, excluding vagus nerve (CN
X), which also serves organs in thoracic and abdominal cavities
 List of CN, impulses sent and functions:
• CN I, Olfactory – nose to brain – sense of smell
• CN II, Optic – eye to brain – vision
• CN III, Oculomotor – brain to eye muscles – eye movements, pupillary
control
• CN IV, Trochlear – brain to external eye muscles – eye movements
• CN V, Trigeminal (opthalmic, maxillary, mandibular branch) – skin & mucus
membrane of head to brain; teeth to brain; brain to chewing muscles –
sensation of face, scalp and teeth; chewing movements
• CN VI, Abducens – brain to external eye muscles – turning eyes outward
• CN VII, Facial – taste buds of tongue to brain; brain to facial muscles –
sense of taste; contraction of muscles of facial expression
• CN VIII, Acoustic (vestibulocochlear) – ear to brain – hearing; sense of
balance
• Cranial Nerves.. cont
 List of CN, impulses sent and functions..cont:
• CN IX, Glossopharyngeal – throat and taste buds of tongue to
brain; brain to throat muscle and salivary glands – sensations of
throat, taste, swallowing, movements, secretion of saliva
• CN X, Vagus – throat, larynx & organs in thoracic & abdominal
cavities to brain; brain to muscles of throat & to organs in thoracic
& abdominal cavities – sensation of throat, larynx & of thoracic &
abdominal organs; swallowing, voice production, slowing
heartbeat, acceleration of peristalsis
• CN XI, Spinal accessory – brain to certain shoulder & neck muscles
– shoulder movements & turning movements of head
• CN XII, Hypoglossal – brain to muscles of tongue – tongue
movements
• Autonomic Nervous System
 Controls activities of smooth muscle, cardiac muscle, and
all glands
 Subdivision of peripheral nervous system
 Primary function is to maintain internal homeostasis
• Strives to maintain a normal heartbeat, constant body
temperature, and normal respiratory pattern
 Two divisions:
• Sympathetic nervous system
• Parasympathetic nervous system
• Autonomic Nervous System
 Two divisions
• Antagonistic
 One slows an action, and the other accelerates the action
 Note: function simultaneously, but have the ability to
dominate each other as the need arises
• Stress
 Sympathetic takes over to prepare body for “fight or flight”
 Heartbeat accelerates, BP increases, adrenal glands increase
secretions
• To calm the body
 Parasympathetic dominates
 Slowing heartbeat and decreasing BP and adrenal hormones
• Effects of Normal Aging on the Nervous System
 Loss of brain weight
 Loss of neurons (1% a year after age 50)
 Cortex losing cells faster than the brainstem
 Remaining cells undergo structural changes
 General decline in interconnections of dendrites
 Reduction in cerebral blood flow
 Decrease in brain metabolism and oxygen utilization
 Neurons may contain senile plaques, neurofibrillary tangles & age
pigment lifofuscin
 Altered sleep/ wakefulness ratio
 Decrease in ability to regulate body temperature
 Decrease in velocity of nerve impulses
 Decreased blood supply to spinal cord causes decreased reflexes
Older Adult Consideration Box
• Neurological Disorder
 As neuron are lost with aging, there is a deterioration in neurological function,
resulting in slowed reflex and reaction time
 Tremors that increase with fatigue are commonly observed in adults
 The sense of touch & the ability for fine motor coordination diminish with
aging
 Most older people possess the ability to learn, but the speed of learning is
slowed. Short-term memory is more affected by aging than long-term memory
 The incidence of physiologic dementia or organic brain syndrome-including
Alzheimer’s disease, Pick’s disease & multiinfarct dementia-increases with
aging
 Incidence of stroke increases with age. Prognosis is affected by the location &
extent of the cerebral damage. Rehab potential after a stroke is often reduced
by advanced age & coexisting medical problem
 Nerve irritation resulting from arthritis, joint injuries or spinal-cord
compression can cause chronic pain or weakness
 Dementia is not a normal consequence of aging but may be result of may
reversible conditions, including anemia, fluid & electrolyte imbalance,
malnutrition, hypothyroidism, metabolic disturbances, drug toxicity, a drug
reaction/idiosyncrasy & hypotension.
• Prevention of neurological problems
 Avoid drug and alcohol use
• Smoking increases lung cancer and lung CA metastasizes to
the brain
 Safe use of motor vehicles
 Safe swimming practices
 Safe handling and storage of firearms
 Use of hardhats in dangerous construction areas
 Use of protective padding as needed for sports
Assessment of the Neurological System
• History
 Essential for diagnosing neurological disease
 Includes specifics about symptoms experienced
 Asses patient understanding & perception of what is happening.
 Obtain info from family members/ significant others may be helpful
 Make sure information is complete
 For patients with suspected neurological conditions presence of many
symptoms of subjective data may be significant. These include the
following:
• Headaches, especially those that first occur after middle age or
those that change in character; headaches that are worse in the
morning or awaken a person from sleep are especially significant
• History..cont
 For patients with suspected neurological conditions
presence of many symptoms of subjective data may be
significant. These include the following..cont:
• Clumsiness or loss of function in an extremity
• Change in visual acuity
• Any new or worsened seizure activity
• Numbness or tingling in one or more extremities
• Pain in an extremity or other part of the body
• Personality changes or mood swings
• Extreme fatigue or tiredness
• Mental Status
 Assessment of patient neurological mental status is
important
 Examination generaly includes orientation (person, place,
time, and purpose), mood and behavior, general
knowledge (such as names of U.S. presidents), and short-
and long-term memory.
 The patient’s attention span and ability to concentrate may
also be assessed
 Note actual patient statement & note actual level of
orientation (name, date, time & purpose), always try
different approach cause patient my learn the correct
answer through repetition
• Level of consciousness
 Level of consciousness (LOC) is the earliest and most sensitive indicator
that something is changing.
 A decreasing level of consciousness is the earliest sign of increased
intracranial pressure.
 LOC has two components
• Arousal (or wakefulness) and
• Awareness.
 Wakefulness is the most fundamental part of LOC. If the patient can
open the eyes spontaneously to voice or to pain, it says that the
wakefulness center in the brainstem is still functioning.
 Awareness, a higher function controlled by the reticular activating
system in the brainstem.
• Level of consciousness
 Awareness has four components:
1. Orientation: person, place, time, purpose
2. Memory: assess short-term memory; do not ask yes or no
questions.
3. Calculation: example, “If you have $2 and your apple costs
$1.25, how many quarters would you get back?”
4. Fund of knowledge: Ask the patient to name the president
and to tell you what’s on the national news (Lower, 2002).
 Restlessness, disorientation, and lethargy may be seen
first.
• LEVELS OF CONSCIOUSNESS
 Alert, Disorientation, Stupor, Semicomatose, Comatose, level &
description below:
• Alert: Responds appropriately to auditory, tactile, and visual stimuli
• Disorientation: Disoriented; unable to follow simple commands,
thinking slowed, inattentive, flat affect.
• Stupor: Responds to verbal commands with moaning or groaning,
if at all
• Semicomatose: Impaired state of consciousness characterized by
obtundation and stupor, from which a patient can be aroused only
by energetic stimulation
• Comatose: Unable to respond to painful stimuli; cornea and
papillary reflexes are absent. The patient cannot swallow or cough.
The patient is incontinent of urine and feces. The EEG pattern
demonstrates decreased or absent neuronal activity.
• Glasgow Coma Scale
 Quick, practical & standardized system for assessing the
degree of consciousness impairment in the critically ill and
for predicting the duration and ultimate outcome of coma,
particularly head injury.
 Neurologic evaluation uses the Glasgow Coma scale as an
indicator of the severity of brain injury.
 The highest possible number of 15 indicates that the
individual has no impairment, while a score of 3 indicates
brain death.
 A score of 6 – 8 is associated with a coma state
• Glasgow Coma Scale
 E: Eye opening
• Spontaneous =4
• To verbal stimuli =3
• To pain stimuli =2
• None =1
 M: motor response
• Obeys commands =6
• Localizes pain =5
• Normal withdrawal flexion = 4
• Decorticate flexion =3
• Decerebrate extension =2
• Flaccid =1
 V: verbal response
• Oriented =5
• Confused conversation =4
• Inappropriate words =3
• Incomprehensible sounds = 2
• None =1
• LANGUAGE AND SPEECH

 Speech is a function of the dominant hemisphere, which is on the left
side of the brain for all right-handed people and most left-handed
people.
 Aphasia
• An abnormal neurological condition in which the language function
is defective or absent because of an injury to certain areas of the
cerebral cortex-Broca’s area in the frontal lobe and Wernicke’s area
in the posterior part of the temporal lobe.
 Aphasia includes all areas of language, including speech, reading,
writing, and understanding. Aphasia has been subdivided as follows:
• Sensory aphasia or receptive aphasia: inability to comprehend the
spoken word or written word.
• Motor aphasia: inability to use symbols of speech (also called
expressive aphasia).
• Global aphasia: inability to understand the spoken word or to
speak.
• LANGUAGE AND SPEECH
 Anomia
• A form of aphasia characterized by the inability to name
objects.
 Dysarthria
• Defined as difficult, poorly articulated speech that usually
results from interference in the control over the muscles of
speech. The general cause is damage to a central or
peripheral nerve.
• The cranial nerves classification
 I (olfactory) - Identification of common odors
 II (optic) - Testing of visual acuity and visual fields
 III (oculomotor) - Testing of ability of eyes to move together in all
directions, testing pupillary response
 IV (trochlear) - Tested with oculomotor; testing eye movements
 V (trigeminal) - Jaw strength and sensation of face corneal reflex
 VI (abducens) - Tested with oculomotor; testing eye movements
 VII (facial) - Ability of face to move in symmetry, identification of tastes
 VIII (acoustic, or vestibulocochlear) - Testing of hearing through
whisper or other means and checking equilibrium and balance.
 IX (glossopharyngeal) - Identification of taste
 X (vagus) - Gag reflex, movement of uvula and soft palate
 XI (spinal accessory) - Shoulder and neck movement
 XII (hypoglossal) - Tongue motion
MOTOR FUNCTION
• Motor function disturbances are the most commonly encountered
neurological symptom
• In general, the parts of the motor status examination include gait and
stance, muscle tone, coordination, involuntary movements, and the
muscle stretch reflexes.
• Reflexes that are usually tested include the biceps, triceps, brachioradialis,
quadriceps, gastrocnemius, and soleus muscles. The examiner taps briskly
over the muscle with a reflex hammer. The response is noted and graded
on a scale, usually from 0 to 4+, with 4+ being hyperreflexic
• The most important feature of any reflex pattern is not the absolute value
on the scale, but the comparison of one side of the body with the other.
• Stick figures are commonly used to record the bilateral values.
• Damage to the nervous system often causes a serious problem in mobility.
A loss of function is called paralysis; a lesser degree of movement deficit
from partial or incomplete paralysis is called paresis.
MOTOR FUNCTION..cont
• Muscles may be flaccid (weak, soft, and flabby and
lacking normal muscle tone), with absent deep tendon
reflexes, or spastic (involuntary, sudden movement or
muscular contraction), with increased reflexes.
• With some muscle problems, the affected muscle shows
small, localized, spontaneous, and involuntary
contractions called fasciculations. With other problems,
clonus (a forced series of alternating contractions and
partial relaxation of a muscle) may occur.
SENSORY AND PERCEPTUAL STATUS
• The sensory examination is the most common difficult
part of the neurological evaluation. Specific alterations in
sensation that should be assessed include pain; touch;
temperature; and proprioception, the sensation
pertaining to spatial-position and muscular-activity
stimuli originating from within the body or to the sensory
receptors that those stimuli activate.
 This sensation gives one the ability to know the
position of the body without looking at it and the
ability to know objects by the sense of touch.
SENSORY AND PERCEPTUAL STATUS..cont

• Unilateral neglect, a condition in which an individual is
perceptually unaware of and inattentive to one side of
the body
• Another perceptual problem is hemianopia or
hemianopsia, which is characterized by defective vision
or blindness in half of the visual field
of one or both eyes.
SENSORY AND PERCEPTUAL STATUS..cont
• It is usually not feasible or necessary to complete the total
neurological examination during shift-to-shift assessments of the
patient.
• In intensive care units, the neurological checks may be done as
frequently as every 15 minutes.
 Factors that are the most important include
1. orientation,
2. level of consciousness,
3. bilateral muscle strength,
4. speech ability,
5. involuntary movements,
6. ability to follow commands, and
7. any abnormal posturing.
Laboratory and Diagnostic Exam
BLOOD AND URINE TESTS

• Urine culture may rule out infection involving the urinary tract.
• Other urine testing may indicate the presence of diabetes insipidus
• Urine drug screens may be done to rule out drug use as a cause of
lethargy or to identify specific drugs ingested
• Arterial blood gas values may be an important diagnostic tool in
monitoring the oxygen content of the blood
• Gases may be altered with neurological diseases suc as Guillain-
Barre syndrome where breathing pattern were altered
• Blood test that are routinely done may help narrow the Dx of
neurological disorder
CEREBROSPINAL FLUID
• Normally there are up to 10 lymphocytes per milliliter of spinal
fluid. An increase in the number of cells may indicate an
infection.
• Infections such as Tuberculosis meningitis often lower the CSF
glucose level
• Bacterial infection such as TB meningitis often lower the CSF
glucose level as well as the chloride levels (culture or smear
exam is done to determine the causative organism in meningitis)
• Spinal-fluid protein is elevated when degenerative disease or a
brain tumor is present
• Blood in the spinal fluid indicates hemorrhage from somewhere
in the ventricular system
• A protein electrophoresis eval may give evidence of neurological
diseases such as Multiple Sclerosis (MS)
CEREBROSPINAL FLUID..cont
• Normal Characteristic of CSF
 Spec Gravity 1.007
 pH 7.35-7.45
 Chloride 120-130 mEq/L
 Glucose 50-75 mg/dl
 Pressure 80-200 mm water
 Total vol 80-200 ml (15ml in ventricle)
 Total protein 15-45 mg/dl – lumbar
10-25 mg/dl – cisternal
5-15 mg/dl – ventricular
 Gamma globulin 6-13% of total protein count
 Cell count
 RBC None
 WBC 0-10 cells (all lymphocytes n
monocytes)
 Culture & sensitivity No organism present
 Serology for syphilis Negative
Other Tests
• Routine skull radiographs of the head and vertebral
column, used in ruling out fractures of the skull and
cervical vertebrae.
• Since the development of the computed tomography (CT)
scan, skull radiographs are not used as extensively as
before.
Computed Tomography (CT) Scan
• The purpose of the CT scan, also called the CAT scan, is to detect
pathologic conditions of the cerebrum and spinal cord using a
technique of scanning without radioisotopes
• If contrast medium is used, it is important for the nurse to
document and report to the physician any history of allergy to
iodine and seafood because iodine is present in the contrast
medium
• No special physical preparation on the patient, takes about 20-30
min without contrast medium and 60 min with contrast medium.
• Painless except discomfort when IV is started for contrast medium
and claustrophobic feeling as head will be placed on a holder while
laying still
• Each image appears specific brain tissue, computer will display areas
of increased densities (e.g tumors or thrombi)
Brain Scan
• The brain scan’s purpose is detecting pathologic conditions of the
cerebrum. It uses radioactive isotopes and a scanner.
• No special physical preparation, patient lay still as the scanner
passes over the brain area
• Procedure takes 45 min for the scanning
• The patient is injected with radioisotope, minimal discomfort may
occur when IV is started for radioisotope
• If mercury is used as isotope, meralluride (mercuhydrin) is
administered several hours before to allow greater concentration of
mercury to circulate the brain tissue, coz it minimizes uptake of
mercury by kidney
• Brain scan is being used less frequently than in the past because of
the excellent results obtained from CT scan and magnetic resonance
imaging (MRI)
Magnetic Resonance Imaging (MRI) Scan
• MRI uses magnetic forces to image body structures.
• Used to detect pathologic conditions of the cerebrum and spinal
cord, as in detection of stroke, multiple sclerosis, tumors, trauma,
herniation & seizures
• MRI is the diagnostic test of choice for many neurological diseases
because it yields greater contrast in the images of soft-tissue
structures than does the CT scan
• The scan involves a magnetic force, hence, the patient is cautioned
to remove watches and any metal from body or clothing before
entering the scanning room.
• Painless procedure takes about 45-60min, minimal discomfort for
lying still and claustrophobia feeling, patient must be warned that
machine may makes loud noises during procedure
• New advanced in MRI techniques include diffusion weighted
imaging and magnetic resonance spectroscopy
Magnetic Resonance Angiography (MRA)

• Magnetic resonance angiography (MRA) uses differential
signal characteristic of flowing blood to evaluate
extracranial and intracranial blood vessels. It provides
both anatomic and hemodynamic information.
• MRA is rapidly replacing cerebral angiography for use in
diagnosing cerebrovascular disease
• Also called cMRA (contrast enhanced MRA) if used in
conjuction with contrast media
Positron Emission Tomography (PET) Scan
• In this procedure the patient receives an injection of
deoxyglucose with radioactive fluorine.
• The area in question is scanned, and a color composite picture
is obtained. Shades of color give an indication of the level of
glucose metabolism; this then can be translated into
indications of a pathologic state.
• PET scan provide non invasive means of determining
biochemical processes that occur in the brain
• There is increased clinical use of PET scan to monitor select
patients following stroke, Alzheimer’s disease, tumors,
epilepsy, and Parkinson’s disease
• Discomfort is minimal, patient must be aware the need to lie
still during scanning, approx 45 min.
The gray outer surface is the surface of

the brain from MRI and the inner
colored structure is cingulate gyrus,
part of the brain's emotional system
visualized with PET.
Photo by Monte S. Buchsbaum, M.D.
Lumbar Puncture
• Performed as part of the Dx workup of the patient who may have a neurological
problem
• A lumbar puncture is done to obtain CSF for examination, to relieve pressure, or to
introduce dye or medication
• It is contraindicated in patients with increased intracranial pressure, because the
withdrawal of fluid may cause the medulla oblongata to herniate downward into
the foramen magnum
• Procedure takes 10-15min, commonly done in patient’s room or the imaging
department, slight pain & pressure may be felt as the dura is entered, sharp
shooting pain down one leg may occur, caused by needle coming close to a nerve
• Done in side positioned with knee and head flexed at acute angle allowing lumber
flexion & separation of the interespinous spaces. Anesthetized the area with local
aesthesis then needle inserted at L4-L5 or L5-s1 interspace. Removed inner needle
for drainage & measure the spinal fluid.
• Manometer is used to measure the pressure
• After the procedure the patient lies flat in bed for several hours.
• Headache is fairly common and is thought to be caused by the loss of spinal fluid.
• If a headache develops, bed rest, analgesics, and ice to the head may help. Opioids
are usually not helpful
LUMBAR
PUNCTURE
(BETWEEN L3–L4)
Position and angle of

the needle when
lumbar puncture is
performed.
Electroencephalogram
• The electroencephalogram (EEG) is used to provide evidence of
focal or generalized disturbances of brain function by measuring the
electrical activity of the brain.
• Among the cerebral diseases assessed by the EEG are epilepsy, mass
lesions (e.g, tumors, abscess, hematoma), cerebrovascular lesions,
and brain injury.
• No special preparation, only rest & quite surrounding before
procedure.
• Usually done first thing in the morning, takes about 1hr to complete
• After procedure patient must rest and assisted to wash the patient
hair to remove the collodion from scalp.
Myelogram
• The myelogram is commonly used to identify lesions in the
intradural or extradural compartments of the spinal canal by
observing the flow of radioppaque dye through the subarachnoid
space.
• The most common lesion for which this test is used is a herniated or
protruding intervertebral disk. Other lesions include spinal tumors,
adhesions, bony deformations, and arteriovenous malformations.
• Procedure takes about 2 hrs, will be slight discomfort as dura
entered and may be asked to assume variety position during
procedure
• Preparation are the same as the lumbar puncture aside from the
injection of dye (ask patient for allergic reaction)
• Patient usually undergoes CT scan 4-6hrs after myelogram
• Headaches are common after the procedure, might be accompanied
by N&V.
• Patient must lay flat for few hours.
Angiograms
• The angiograms (cerebral arteriography) is a procedure used to visualize
the cerebral arterial system by injecting to visualize the cerebral system by
injecting radiopaque material.
• It allows the detection of arterial aneurysms, vessel anomalies, ruptured
vessels, and displacement of vessels by tumors or masses.
• Clear liquid only before procedure, some other facility require NPO
• Asses allergic reaction to iodine
• Takes about 2-3hrs, may experience discomfort lying still for that time
period. Supine position on radiograph table
• When dye injected may experience feeling or extremely hot and seeing
flashes of light.
• After procedure bed rest is ordered for 4-6hrs, VS checked every 15mins,
neurological assesment every VS check, asses puncture site for hematoma
• Patient may be at risk for cerebral vascular accident as well as increase in
intracranial pressure.
• Any changes in LOC must be reported promptly
• MRA is replacing cerebral ateriography in some facility
CAROTID DUPLEX
• Combined ultrasound & Doppler technology
• Amplified response & graphic record & sound registers
blood flow velocity indicating stenosis of a vessel
• Non invasive studies that evaluates carotid occlusive
disease
• Usually ordered on Transient Ischemic Attack patient to
determine the pathology of the carotid
ELECTROMYOGRAM
• Used to measure the contraction of a muscle in response
to electrical stimulation
• Provide evidence of lowere motoneuron disease; primary
muscle disease; defects in transmission of electrical
impulses at NMJ, such as in Myasthenia gravis
• Takes 45min for muscle study, there will be discomfort
when electrode inserted into muscle & when electrical
current is used. Muscle may ache afterwards
• Asses signs of bleeding after procedure at the injection
sites.
• May need analgesic for discomfort & rest period
Echoencephalogram
• Uses ultrasound to depict the intracranial structures of
the brain
• Helpful in detecting ventricular dilation & major shift of
midline structures in the brain as result of expanding
lesion
• Procedure is similar to brain scan
Common Disorders of the Neurological System
• Headaches
 Etiology/pathophysiology
• The exact mechanism of head pain is not known. Although the
skull and brain tissues are not able to feel sensory pain, pain
arises from the scalp, its blood vessels and muscles, and from the
dura mater and its venous sinuses.
• Pain also arises from the blood vessels at the base of the brain
and from cervical cranial nerves. Blood vessels may dilate and
become congested with blood
• Headaches can be classified as vascular, tension, and traction-
inflammatory
1. Vascular headache, include migraine, cluster, and hypertensive
headaches
2. Tension headache, arise from medical problems such as cervical
arthritis.
3. Traction-inflammatory headaches include those caused by infection,
intracranial or extracranial causes, occlusive vascular structures, and
temporal arteritis.
• Headaches (continued)
 Clinical manifestations
• Headache pain may be worse by stress or tension.
• Knowledge of the patient’s perception of the effect of stress on
the pain is important in planning effective interventions.
• Migraine headaches
 Prodromal (early s/s ofsigns and symptoms that occur before the
acute attack. These may include any of the following:
1. Visual field defects
2. Experiencing unusual smells or sounds
3. Disorientation
4. Paresthesias and,
5. In rare cases, paralysis of a part of the body.
 Clinical manifestations...cont
• During a migraine headache s/s may include:
 N&V, sensitivity to light, chilliness, fatigue, irritability, diaphoresis,
edema & other signs of autonomic dysfunction
• Abnormal metabolism of serotonin, a vasoactive neurotransmitter
found in platelets & cells of the brain, plays a major role.
 Assessment
• Include the patient’s understanding of the headache, possible
causes and any precipitating factors
• Important to determine what measures relieve the symptoms as
well as the location, frequency, pattern & character of the pain
• Includes the site of return f the headache, time of day, intervals
between headaches
• Initial onset of the headache, presence of any symptoms that
occur before the headache or associated symptoms, the presence
of allergies and any family history of similar headache patterns are
also important to asses
 Assessment..cont
• Objective date include any behavior indicating stress, anxiety
and pain
• Changes in ADL, as abnormally raised temperature n
presence of sinus drainage may be important
• Document abnormality during physical exam of neurological
assessment
 Diagnostic test
• Usual testing includes neuro exam, a CT scan (MRI or PET),
brain scan, skull radiograph and lumbar pucture
• Lumbar pucture is contraindicated if increased intracranial
pressure exist, or if brain tumor is suspected as it may cause
brain herniation. CT scan is the preferable test in this
situation.
 Medical management
• Diet: limit MSG, vinegar, chocolate, yogurt, alcohol,
fermented or marinated foods, ripened cheese, cured
sandwich meat, caffeine, and pork
• Psychotherapy
• Medications
 Migraine headaches
o Aspirin, acetaminophen, ibuprofen
o Ergotamine tartrate
o Codeine
o Inderal
• Medical management...cont
 Acetylsalicylic acid (aspirin) may help relieve migraine pain.
 Ergotamine tartrate preparations taken early in the attack may prevent
progression of the headache. These drugs act by constricting cerebral
blood vessel walls and reducing cerebral blood flow.
• Reduces inflammation and may reduce pain transmission
• Given orally, sublingually, rectally or by injection
• Can be combined with caffeine, phenobarbital & belladona
• Side effects of ergot preparations include nausea, vomiting,
numbness and tingling, muscle pain, and changes in heart
rate
• They cannot be taken by pregnant women because they
stimulate contractions of the uterine smooth muscle
• Medical management…cont
 Drugs that are Classified as selective serotonin receptor agonists, these
drugs are all indicated to treat acute migraine (with or without aura) in
adults:
• Eletriptan (Relpax)
• Almotriptan (Axert),
• Frovatriptan (Frova),
• Naratriptan (Amerge),
• Rizatriptan (maxalt),
• Sumatriptan (Imitrex), and
• Zolmigriptan (Zomig)
 The Triptan are thought to act on receptors in the extracerebral,
intracranial vessels that become dilated during a migraine attack.
Stimulating this receptor constricts cranial vessels, inhibit
neuropeptide release and reduces nerve impulse transmission along
trigeminal pain pathways.
 Triptans relieve N&V and photphobia assicuated with acute migrane
attack
• Medical management ..cont

 Other drugs that maybe used include nonopioid analgesics such as
phenacetin, acetaminophen (Darvocet N).
 Propranolol (Inderal) has been used in the prophylactic treatment of
migraine and other vascular headaches.
 Intranasal lidocaine has been used with some relief.
 Tension headaches
• Non-narcotic analgesics
 Traction-inflammatory headaches
• Treat cause
 Comfort measures
• Cold packs to forehead or base of skull
• Pressure to temporal arteries
• Dark room; limit auditory stimulation
• Nursing Interventions and Patients Teaching
 Because stress and emotional upsets may precipitate some
headaches and worsen others, relaxation and rest should
be facilitated. This includes relaxation techniques, planned
sleeping hours, and regular rest periods.
 Alcohol should not be used to relieve tension because it
may become addicting and has been found to be a
significant cause of cluster headaches, especially ones
caused by tension.
• Nursing Interventions and Patients Teaching
 Comfort measures.
• Other treatments that may be helpful for a patient
with a headache include cold packs applied to the
forehead or base of the skull.
• Pressure applied to the temporal arteries may be
helpful.
• People with migraine headaches, especially, are
usually most comfortable lying in a dark room with
minimal auditory stimulation.
• Education and Teaching:
1. Avoidance of factors that trigger headaches,
2. Relaxation techniques including biofeedback,
3. Importance of maintaining regular sleep patterns,
4. Medications to be used (including dose, actions, and side effects), and
5. The importance of follow-up care.
• Prognosis
 With proper treatment the person with headaches can expect to live
a normal life.
 Changes in lifestyle may need to occur, especially during acute
episodes of headache pain.
 The person may have to adjust to periodic headaches and will need to
rest until the headache resolves.
• Neurological Pain
• Neurological pain other than headache is common. The
transmission of pain is not fully understood, but patients may
experience disabling pain either caused by a disorder within the
nervous system (lesion in nerve roots, thalamus, central pain tract
[lateral spinothalamic]) or caused peripherally at a distant part of
the body
• Pain receptor can be activated by cellular damage certain
chemicals such as histamine, heat, ischemia, muscle spasm &
sensation of cold & pruritus that go beyond specific level of
intensity.
• Pain that is described as unbearable and does not respond to
treatment is classified as intractable. It is chronic and often
debilitating, and may prevent the patient from functioning in ADLs.
• Neurological Pain..cont
 Assessment
• Subjective:
 Perception of pain is highly subjective
 Asses patient understanding of pain
 Any precipitating factors
 Measures to relieve stress, including medication & Usual coping
patterns of the patient when under stress
 Site, quality, frequency & nature of the pain
 Presence of associated symptoms & measures that makes it worse
are important too
• Objective:
 Any behavioral signs indicating pain or stress
 Change in ADLs
 Muscle weakness or wasting
 Vasomotor responses (flushing)
 Abnormalities in spinal reflexes
 Abnormalities noted during the sensory examination
 Diagnostic Test
• Diagnostic tests for the patient in pain may include electrical
stimulation used to define the pain to a greater degree.
Psychological testing may be part of the workup.
• If back or neck pain is present, a myelogram is usually performed.
• Nonsurgical methods of pain control include
 Transcutaneous electrical nerve stimulation (TENS)
 Spinal cord stimulation.
 Both techniques use electrodes applied near the site of pain or
on or around the spine.
 Acupuncture has also been used to treat patients with neurological
pain.
 Medical management..cont
• Nerve block used to control intractable pain
• By injecting local anesthetic, alcohol or phenol close enough
to a nerve to block the conduction of impulses
• Sources of pain treated include trigeminal neuralgia, cancer,
or pheripheral vascular disease
• Duration of effect is from months to years
• Epidural catheter is used to control pain & spacticity
• Continued Meds are given
• Medications are often used to treat patients with
neurological pain.
 Gabapentin (Neurontin) to control neurological pain
 Nonopioid analgesics such as acetaminophen, propoxyphene
(Darvon), phenacetin, and acetylsalicylic acid.
 Opioids may be prescribed, as well as muscle relaxants, but
these drugs may led to abuse.
• The emphasis should be on helping the patient learn other
measures to control the pain.
• Surgical methods of pain control
 In cases of intractable pain that does not respond to
more conservative measures, surgery may be
necessary to reduce or abolish pain.
 Neurosurgical procedures that may be done include
neurectomy, rhizotomy, cordotomy, and
percutaneous cordotomy.
o Side effects of the procedures (cordotomy) include
postural hypotension, inability to feel hot or cold, and
possibly motor and bowel dysfunction function.
 Nursing Interventions and Patient Teaching
• Comfort measures.
 The patient assumes the most comfortable position.
 Nurse should help the patient to find a comfortable position
and may need to actively assist the patient in turning or
moving
 Straining may intensify pain, so stool softener may be needed.
Offer prune juice & high fiber diet with 2000ml/ day fluid or
more
• Promotion of rest and relaxation.
 As with headache, stress and emotional upsets may
precipitate or exacerbate neurological pain. Rest and
relaxation should be facilitated, with planned sleeping hours
and rest periods as needed.
 Some patients with pain, especially intractable pain, may
respond well to psychotherapy.
 Prognosis
• As with headache pain, neurological pain can in most cases
be treated adequately. Lifestyle changes may be helpful in
allowing the person to live a full life.
• Increased intracranial pressure
• Complex grouping of events that occurs because of multiple
neurological conditions
• Occurs suddenly, can progress rapidly, often requires surgical
intervention
• Considered as an increase in any content of the cranium
• Space-occupying lesions, cerebrospinal problems, cerebral
edema
• Since cranial vault is rigid and nonexpandable, buildup
pressure may occur in weeks, or rapidly depending on cause.
• Usually involved one side of the brain, but both will
eventually involved

 Etiology/pathophysiology..con
t
• Normal ICP = 4 – 13
mmHg
• Any sustained increase in
ICP is dangerous hence
early detection and
treatment are vital before
complications occur
• Neuron tissue death will
begin within 4 – 6
minutes if oxygen is not
supplied
• Increased intracranial pressure..cont
 Etiology/pathophysiology..cont
• How it happened:
 Increased pressure in cranial cavity compensated by venous
compression & cerebrospinal displacement. As pressure
increased the cerebral blood flow decreases causing
inadequate perfusion to the brain, starting a vicious cycle that
causes PCO2 to increase and PO2 & pH decrease. These
causing vasodilation and cerebral edema causing further
increased intracranial pressure and even greater increase in
pressure as compression of neural tissue increased.
 When pressure is greater than the ability to compensate,
pressure is exerted on surrounding structure where the
pressure is lower, this movemenet of pressure is called
supratentorial shift, which can result in herniation
 Etiology/pathophysiology..cont
• How it happened..cont
 Brainstem is compressed at various levels, which in turn
compresses the vasomotor center, posterior cerebral artery,
oculomotor nerve, corticospinal nerve pathway and the fibers
of the ascending reticular activating system as a result of
herniation of the brain
 Rise in systolic pressure and an unchanged diastolic pressure,
resulting in a widening pulse pressure, bradycardia &
abnormal respiration are late sign of increased ICP and
indicating that brain is about to herniate.

 Assessment
• Subjective
 Presence of any visual changes such as diplopoa or double
vision
 Change in patient personality
 Change in the ability to think
 Presence of nausea or pain, especially headache is important
 Headache thought resulting from venous congestion & tension
in the intracranial blood vessels as the cerebral pressure rises
 Increase intensity with coughing, straining at stool or stooping
 Usually present early mornings and may awaken patient from
sleep
• Objective
 Change of LOC (earliest sign of increased ICP)
o Disorientation, restlessness or lethargy
 It’s important to chart what is seen not what is inferred

 Pupillary sign may change responsiveness as it’s controlled by
cranial nerve III (oculomotor nerve)
 As the brain herniates, the nerve is being compressed-with the
top part of the nerve being affected first. The ipsilateral pupil
(when lesion in one hemisphere) remains dilated & incapable of
constricting
 Once both halves of the brain become affected bilateral pupil
dilation and fixation occur
 Pupil that is fixed & dilated is called blown pupil, an ominous sign
that must be reported to the MD immediately
 BP & pulse will increase in increased ICP, causing systolic BP to rise
 If pressure continues widening pulse pressure will occur
• Objective..cont
 Pressure will increased parasympathetic transmission of impulses
through the vagus nerve to the heart, causing slowing of the pulse
 Cushing’s response will exist, it is a widened pulse pressure, increase
systolic BP and bradycardia. Cushing’s is considered and important Dx
sign of late stage brain herniation
 Breathing pattern may be deep & stertorous (snorelike) or periodic
(Cheyne-Stokes) respiration
 Ataxic breathing may occur (an irregular & unpredictable breathing
pattern with random, shallow, and deep breath & occasional pauses)
 As Intracranial pressure increases to fatal levels, respiratory paralysis
occur
 Seen in patient with damage to medulla oblongata
• Objective..cont
 High, uncontrolled temperature occur due to a failure of
the thermoregulatory center
 Presence of Babinski’s reflex, hyperflexia, rigidity &
seizures are additional signs of decreased motor function
due to compression of the upper motoneuron pathway
(corticospinal tract) interrupting transmission of impulses
to the lower motoneuron
 Herniation of the upper part of the brainstem may
produce characteristic posturing when patient is
stimulated (see picture left)
• Objective..cont
 Vomiting & singultus are two objective sign.
 Vomiting is often projectile in nature & usually not preceded
by nausea (called unexpected vomiting)
 Singultus is caused by compression of the vagus nerve (CN X)
when brainstem herniation occur.
 Papilledema, can be detected by using ophtalmoscope (done
by MD’s) as optic disk becomes edematous, reitna is also
compressed, damaged retina cannot detect light rays as blind
spot enlarges as visual acuity lessened. Papilledema is also
called choked disk
 Urinary incontinence
 Bulging fontanelles
 Leakage of CSF (clear yellow or pinkish fluid) from the nose
(rhinorrhea) or ear (otorrhea).
 Herniation of the Brain
• When Inc. ICP exerts enough pressure to displace a portion
of the brain, herniation can occur. The brain would herniate
through a large foramen in the occipital bone, which lies
between the cranial and spinal cavities.
• Herniation causes severe injury to the brain because of
prolonged hypoxia to parts of the brain that control the vital
functions of the body, such as breathing and blood
circulation. The result is brain death and death of the patient.
• When ICP is elevated, lumbar puncture is contraindicated ,
because it can cause the brain to herniate.
• Increased intracranial
pressure..cont
 Diagnostic Test
• CT or MRI scan, shows
structural herniation &
shifting of the brain
• Most of the time acute
increased intracranial
pressure is an emergency
there is little time for Dx test
• Dx must be based on
frequent & careful
observation & neurological
testing
• Presence of even subtle
changes may be very
significant
• Internal measuring device ICP Monitoring
used to Dx increased
intracranial pressure (see
right pic)
• Treat cause if possible
• Mechanical decompression
 Craniotomy, bone flap is removed then replaced
 Craniectomy, bone flap is removed & not replaced (often
done when pressure is high)
 Drainage of the ventricles or any subdural hematoma
may be beneficial as well
• Internal monitoring devices
• Endotracheal intubation may be necessary
• ABG analysis to guide O2 therapy (to maintain PAO2 @
100mmHg)
• Three types of medications are usually administered to patients
with increased intracranial pressure:
 Osmotic Diuretics, Corticosteroids & Anticonvulsants.
 Example of drugs:
1. Osmotic diuretics (mannitol), Loop diuretics (furosemide
(Lasix), bumetanide (Bumex), and ethacrynic acid
(Edecrin)
2. Midazolam (sedative, hypnotic, antianxiety) and
atracurium besylate (neuromuscular blocker)
3. Corticosteroids – Dexamethasone – to control edema
surrounding cerebral tumors and abcesses (monitor
glucose level).
4. Anticonvulsants - Phenytoin (Dilantin), Fosphenytoin
(Cerebyx) through IV for better absorbtion– To prevent
seizures
 Nursing Interventions and Patients Teaching
• Therapeutic measures to reduce venous volume may be
implemented.
 Elevate the head of the bed to 30 to 45 degrees to promote
venous return.
 Place the neck in a neutral position (not flexed or extended) to
promote venous drainage.
 Position the patient to avoid flexion of the hips, waist, and
neck as well as rotation of the head, especially to the right.
Extreme hip flexion is avoided because this position causes an
increase in intraabdominal and intrathoracic pressures, which
can produce a rise in ICP.
 Instruct the patient to avoid isometric or resistive exercises.
 Restrict fluid intake.
 Nursing Interventions and Patients Teaching
• Therapeutic measures to reduce venous volume may be
implemented.
 Implement measures to help the patient avoid Valsalva’s maneuever
(any forced expiratory effort against a closed airway, such as straining
to have a stool). Enemas and laxatives should be avoided if possible.
 Have a Foley catheter in place if the patient is not alert because of the
large amount of urine that is produced
 Perform suctioning only as necessary and for no longer than 10
seconds with admission of 100% oxygen before and after to prevent
decreases in the PaO2.
 Administer oxygen via mask or cannula to improve cerebral perfusion.
 Use a hypothermia blanket to control body temperature (increased
body temperature increases brain damage).
 Prognosis
• The prognosis for the patient with increased intracranial
pressure depends on the cause and how rapid with which it
is treated.
• The nurse assumes a very important role in monitoring the
patient for signs and symptoms of increased pressure.
• After herniation of the brain has begun as a result of
pressure, there is little chance for complete reversal without
significant brain damage.
 Clinical manifestations/assessment
• Diplopia
• Headache
• Decreased level of consciousness
• Pupillary signs
• Increased intracranial pressure (continued)

 Clinical manifestations/assessment (continued)
• Widening pulse pressure
• Bradycardia
• Respiratory problems
• High, uncontrolled temperatures
• Positive Babinski’s reflex
• Seizures
• Posturing
• Vomiting
• Singultus
• Increased intracranial pressure (continued)
 Medical management/nursing interventions
• Treat cause if possible
• Mechanical decompression
 Craniotomy
 Craniectomy
• Internal monitoring devices
• Disturbances in muscle tone and motor function

• Damage to the nervous system causes serious problems in
mobility
• Flaccid or hyperreflexic muscle tone
• Clumsiness or incoordination
• Abnormal gait
• Disturbances in muscle tone and motor function
(continued)
• Muscle relaxants
• Protect from falls
• Assess skin integrity
• Positioning
• Sit up and tuck chin when eating
• Encourage patient to assist with ADLs
• Emotional support
Other Disorders of the Neurological System
• Epilepsy or seizures
• Transitory disturbance in consciousness or in motor, sensory,
or autonomic function due to sudden, excessive, and
disorderly discharges in the neurons of the brain; results in
sudden, violent, involuntary contraction of a group of
muscles
• Types: grand mal; petit mal; psychomotor; Jacksonian-focal;
myoclonic; akinetic
• Status epilepticus
• Epilepsy or seizures (continued)
• Depends on type of seizure
• Aura
• Postictal period
• During seizure: protect from aspiration and injury
• Anticonvulsant medications
• Surgery
 Removal of brain tissue where seizure occurs
• Epilepsy or seizures (continued)
 Medical management/nursing interventions (continued)
• Adequate rest
• Good nutrition
• Avoid alcohol
• Avoid driving, operating machinery, and swimming until
seizures are controlled
• Good oral hygiene
• Medical alert tag
Degenerative Diseases
• Multiple sclerosis
• Degenerative neurological disorder with demyelination of
the brain stem, spinal cord, optic nerves, and cerebrum
Figure 54-13
Pathogenesis of multiple sclerosis.

• Multiple sclerosis (continued)
• Visual problems
• Urinary incontinence
• Fatigue
• Weakness
• Incoordination
• Sexual problems
• Swallowing difficulties
• Multiple sclerosis (continued)

• No specific treatment
• Adrenocorticotropic hormone (ACTH)
• Steroids
• Valium
• Betaseron (interferon beta-1b)
• Avonex (interferon beta-1a)
• Pro-banthine; urecholine
• Bactrim, Septra, and Macrodantin
• Parkinson’s disease
• Deficiency of dopamine
• Muscular tremors; bradykinesia
• Rigidity; propulsive gait
• Emotional instability
• Heat intolerance
• Decreased blinking
• “Pill-rolling” motions of fingers
Figure 54-14
Nigrostriatal disorders produce parkinsonism.

• Parkinson’s disease (continued)
• Medications
 Levodopa
 Sinemet
 Artane
 Cogentin
 Symmetrol
• Surgery
 Pallidotomy
• Alzheimer’s disease
• Impaired intellectual functioning
• Degeneration of the cells of the brain
• Alzheimer’s disease (continued)

• Early stage
 Mild memory lapses; decreased attention span
• Second stage
 Obvious memory lapses
• Third stage
 Total disorientation to person, place, and time
 Apraxia; wandering
• Terminal stage
 Severe mental and physical deterioration
• Alzheimer’s disease (continued)
• Medications
 Agitation: lorazepam; Haldol
 Dementia: Cognex; Aricept
• Nutrition
 Finger foods; frequent feedings; encourage fluids
• Safety
 Remove burner controls at night
 Double-lock all doors and windows
 Constant supervision
• Myasthenia gravis
• Neuromuscular disorder; nerve impulses fail to pass at the
myoneural junction; causes muscular weakness
• Ptosis; diplopia
• Skeletal weakness; ataxia
• Dysarthria; dysphagia
• Bowel and bladder incontinence
• Myasthenia gravis (continued)
• Anticholinesterase drugs
 Prostigmin
 Mestinon
• Corticosteroids
• May require mechanical ventilation
• Amyotrophic lateral sclerosis (ALS)
• Motor neurons in the brain stem and spinal cord gradually
degenerate
• Electrical and chemical messages originating in the brain do
not reach the muscles to activate them
• Lou Gehrig’s disease
• Amyotrophic lateral sclerosis (ALS) (continued)
• Weakness of the upper extremities
• Dysarthria; dysphagia
• Muscle wasting
• Compromised respiratory function
• No cure
• Rilutec (Riluzole)
• Multidisciplinary ALS teams; emotional support
• Huntington’s disease
• Overactivity of the dopamine pathways
• Genetically transmitted
• Abnormal and excessive involuntary movements (chorea)
• Ataxia to immobility
• Deterioration in mental functions
• Huntington’s disease (continued)

• No cure; palliative treatment
• Antipsychotics
• Antidepressants
• Antichoreas
• Safe environment
• Emotional support
• High-calorie diet
Vascular Problems
• Stroke (cerebrovascular accident)
• Abnormal condition of the blood vessels of the brain:
thrombosis; embolism; hemorrhage
• Results in ischemia of the brain tissue
• Headache
• Sensory deficit
• Hemiparesis; hemiplegia
• Dysphasia or aphasia
Figure 54-16
Three types of stroke.

Vascular Problems
• Stroke (cerebrovascular accident) (continued)
• Thrombosis or embolism
 Thrombolytics
 Heparin and Coumadin
• Decadron
• Neurological checks
• Feeding tube
• Physical, occupational, and/or speech therapy
Cranial and Peripheral Nerve Disorders
• Trigeminal neuralgia
• Degeneration of or pressure on the trigeminal nerve; tic
douloureux
• Excruciating, burning facial pain
• Tegretol
• Surgical resection of the trigeminal nerve
• Avoid stimulation of face on affected side
• Bell’s palsy (peripheral facial paralysis)
• Inflammatory process involving the facial nerve
• Facial numbness or stiffness
• Drawing sensation of the face
• Unilateral weakness of facial muscles
• Reduction of saliva
• Pain behind the ear
• Ringing in ear or other hearing loss
• Bell’s palsy (peripheral facial paralysis) (continued)
• Electrical stimulation
• Moist heat
• Steroids
• Massage of the affected area
• Facial exercises
• Guillain-Barré syndrome
• Inflammation and demyelination of the peripheral nervous
system
• Possibly viral or autoimmune reaction
• Guillain-Barré syndrome (continued)
• Symptoms are progressive
• Paralysis usually starts in the lower extremities and moves
upward; may stop at any point
• Respiratory failure if intercostal muscles are affected
• May have difficulty swallowing, breathing, and speaking
• Guillain-Barré syndrome (continued)
• Adrenocortical steroids
• Apheresis
• Mechanical ventilation
• Gastrostomy tube
• Meticulous skin care
• Range-of-motion exercises
• Meningitis
• Acute infection of the meninges
• Bacterial or aseptic
• Meningitis (continued)
• Headache; stiff neck
• Irritability; restlessness
• Malaise
• Nausea and vomiting
• Delirium
• Elevated temperature, pulse, and respirations
• Kernig’s and Brudzinski’s signs
• Meningitis (continued)
• Antibiotics
 Massive doses
 Multiple types
 IV or intrathecal
• Steroids
• Anticonvulsants
• Dark, quiet room
• Intracranial tumors
• Benign or malignant
• Primary or metastatic
• May affect any area of the brain
• Intracranial tumors (continued)
• Headache
• Hearing loss
• Motor weakness
• Ataxia
• Decreased alertness and consciousness
• Abnormal pupil response and/or unequal size
• Seizures
• Speech abnormalities
• Intracranial tumors (continued)
• Surgical removal of tumor
 Craniotomy
 Intracranial endoscopy
• Radiation
• Chemotherapy
• Combination of above
Trauma
• Craniocerebral trauma
• Motor vehicle and motorcycle accidents, falls, industrial
accidents, assaults, and sports trauma
• Direct trauma: head is directly injured
• Indirect trauma: tension strains and shearing forces
• Open head injuries
• Closed head injuries
• Hematomas
Trauma
• Craniocerebral trauma
• Headache
• Nausea
• Vomiting
• Abnormal sensations
• Loss of consciousness
• Bleeding from ears or nose
• Abnormal pupil size and\or reaction
• Battle’s sign
Trauma
• Craniocerebral trauma (continued)
• Maintain airway
• Oxygen
• Mannitol and dexamethasone
• Analgesics
• Anticonvulsants
Trauma
• Spinal cord trauma
• Automobile, motorcycle, diving, surfing, other athletic
accidents, and gunshot wounds
• Fracture of vertebra
• Complete cord injury
• Incomplete cord injury
Figure 54-22
Mechanisms of spinal injury.

Trauma
• Spinal cord trauma (continued)
• Loss of muscle function depends on level of injury
• Spinal shock
• Autonomic dysreflexia
• Sexual dysfunction
Trauma
• Spinal cord trauma (continued)
• Realignment of bony column for fractures or dislocations:
immobilization; skeletal traction
 Surgery for spinal decompression
• Methylprednisolone
• Mobility: slowly increase sitting up
• Urinary function: Foley catheter; bladder training
 Intermittent catheterization
• Bowel program
Nursing Process
• Nursing diagnoses
 Autonomic dysreflexia
 Communication, impaired
 Coping, compromised family
 Disuse syndrome, risk for
 Grieving
 Infection, risk for
 Knowledge, deficient
 Memory, impaired
Nursing Process
• Nursing diagnoses (continued)
 Mobility, impaired physical
 Nutrition, imbalanced: less than body requirements
 Pain, acute, chronic
 Self-care deficit
 Swallowing, impaired
 Thought process, disturbed
 Tissue perfusion (cerebral), ineffective
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Care of The Patient With A Neurological Disorder

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Care of The Patient With A Neurological Disorder

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CARE OF THE PATIENT

 2 main structural divisions – cont’d

A, Diagram of a typical neuron. B, Scanning electron micrograph of a

o Motor speech (ability to speak)

o Motor ability – directs movements of body; left side controls the

pain, and temperature

o Determination of left from right

o Determination of shapes, sizes and distances

o Integration of auditory stimuli

o Understanding of the written word

Sagittal section of the brain (note position of midbrain).

• Coverings of brain and spinal cord

Neural pathway involved in the patellar reflex.

• LANGUAGE AND SPEECH

SENSORY AND PERCEPTUAL STATUS..cont

BLOOD AND URINE TESTS

Magnetic Resonance Angiography (MRA)

The gray outer surface is the surface of

Position and angle of

• Medical management ..cont

• Increased intracranial pressure

• Increased intracranial pressure..cont

 It’s important to chart what is seen not what is inferred

• Increased intracranial pressure (continued)

• Disturbances in muscle tone and motor function

Pathogenesis of multiple sclerosis.

• Multiple sclerosis (continued)

Nigrostriatal disorders produce parkinsonism.

• Alzheimer’s disease (continued)

• Huntington’s disease (continued)

Three types of stroke.

Mechanisms of spinal injury.

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